17. Ethics

We hold these truths to be self-evident that all patients are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are autonomy, informed consent, pursuit of health, and the right to peaceful death.

17.1 Autonomy

Definition: An inherent right of a patient with capacity or competence to be responsible for and make decisions regarding one’s life, health, and well-being.


Medical determination

Can the patient make an informed decision at this point in time?

Loss of capacity occurs when the patient has acute deterioration in cognitive function (e.g., when patient is acutely psychotica or has acute confusion due to encephalitis).


Legal determination (determined after legal proceedings)

Can the patient make an informed decision at any point in time?

Loss of competence occurs when one has chronic underlying cognitive dysfunction resulting in failure to make sound decisions (e.g., patients with mental disabilities or advanced Alzheimer’s disease).

They require guardianship for financial or health care-related decisions.

aCommon red herring in a test question is a patient with a stable psychiatric diagnosis such as schizophrenia with no acute psychotic symptoms. These patients commonly have the capacity to make their own decisions.

In situations where a patient with capacity does not want to undergo recommended test, or hear about diagnosis, or is refusing treatment, do the following:

  • First, always try to find out the underlying reason.

  • If the answer choices in exam do not involve an open-ended question, the right answer is likely what the patient wants, even if it goes against your medical judgment.

A competent patient without loss of capacity has the right to refuse hearing the diagnosis and refuse life-saving treatment.

Patient loses autonomy when:

Example scenarios

The patient is deemed to likely harm others

  • Refusing treatment or quarantine with communicable disease that presents high risk to communitya: Cholera, diphtheria, active infectious TB, plague, small pox, yellow fever, viral hemorrhagic fever, severe acute respiratory syndrome (SARS), pandemic flu, meningococcal meningitis, etc.

  • Intent of rape or homicide

The patient is deemed to likely harm one-self

Suicide risk

aIn patients with communicable disease, public health authorities and physicians must balance the magnitude of the public health risk against the rights of the individuals or groups.

A pregnant patient has the right of autonomy and can refuse treatment even if it puts fetus at risk.

17.2 Patient Confidentiality, Which Includes HIPAA (Health Insurance Portability and Accountability Act)

  • Do not give patient’s information to anyone else without his/her consent. Do not discuss patient’s case in public spaces where it can be overheard.

  • Disclosure of health information needed for patient care and other important purposes (e.g., specialty consultation service) is allowed.

  • In cases where there is a risk to third party, patient loses the right of confidentiality, e.g., sexually transmitted disease (STD),

    1 STD (e.g., HIV) and confidentiality

    First step is to encourage patient to inform all people at risk (e.g., all sexual partners).

    If patient declares unwillingness to inform his/her sexual partner/s, next step is to inform the local health department. They will subsequently identify the people at risk and inform them.

    harm to others (intent of rape or homicide), or high-risk communicable disease as above.

17.3 Decision Making Process for an Adult Who Is Not Able to Make Decision for Self (e.g., Loss of Capacity Due to Acute Confusion)

First step is to look for the following (given below in order of preference):

  • Previous written advanced directives, or “verified” prior oral directive (i.e., in presence of a “health care provider” and an adult witness).

  • Designated health care proxy.

If none of the above is available, find out who makes health care-related decisions for the patient (i.e., who is the surrogate decision maker?).

The surrogates can be appointed from the following list, given in order of priority:

  • Legal guardian (power of attorney = POA). This is different from health care proxy.

    2 A healthcare proxy is considered to represent patient themselves. They can withdraw life-saving measures, against physician’s judgement. However a surrogate decision maker by themselves cannot withhold or withdraw lifesaving emergency measures against the judgment of physician.

    For nonemergent cases, when a surrogate makes a decision that contradicts physician’s judgment, NSIM is to get judicial or institutional (e.g., hospital ethics committee) review.

  • Spouse or House partner (the one who lives with the patient).

  • Offspring >18 years of age.

  • Parents.

  • Siblings.

  • Close friend.

Dec 11, 2021 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on 17. Ethics
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